Free Minds & Free Markets

Everyone's making money in the market for body tissue -- except
the donors.

Alistair Cooke's body lay cold in the embalming room
of an East Harlem funeral home, suspended in the brief limbo
between death and cremation. A "cutter" soon arrived to make a
collection. He sliced open Cooke's legs, sawed the bones from the
hip, and took them away. The quintessentially British presenter of
Masterpiece Theatre and Alistair Cooke's
America—the face of genteel, urbane Albion to millions of
Americans—was being carved up for parts.

Cooke had died on March 30, 2004, the victim of a
cancer that spread from lung to bone. He left behind a 95-year-old
disease-ridden corpse. Susan Kittredge, Cooke's daughter, was
mindful only of the potentially exorbitant funerary expenses and
flipped through the yellow pages in search of a good price. She
eventually settled on a funeral home with a $595 cremation fee.

The home, East Harlem's New York Mortuary Service,
promised Kittredge a box of ashes but said nothing of its bigger
plans for her father, who would not make it to the cremator whole.
For a fee, the funeral director gave a New Jersey tissue
procurement agency access to Cooke's remains. His bones, worth some
$7,000, were prepped for resale, and his records were falsified to
alter his age and cause of death. Three days later, as promised,
Susan received a cardboard box of ashes by mail.

Alistair Cooke's remains were only the most famous of
more than a thousand bodies plundered by Michael Mastromarino,
owner of Biomedical Tissue Services (BTS). He had a simple business
model: Pay funeral directors for access to bodies and resell bones,
heart valves, spines, and other tissues to biotech firms in need of
spare parts.

A former dental surgeon, Mastromarino was familiar
with the biotech industry and its rising demand for transplantable
tissue. While he was a legitimate practitioner, he had co-authored
a book about the benefits of replacing old with new, buoyantly
titled Smile: How Dental Implants Can Transform Your Life.
He stopped transforming lives through maxillofacial surgery six
years ago, when his predilection for self-medication led to
trouble. He botched a surgery, and the patient charged that he was
stoned on Demerol as he did so. He lost the trust of his patients,
and then he lost his license. BTS was an attempt at fiscal
redemption, and it proved very lucrative.

As the scandal unraveled in 2005, prosecutors
revealed that Mastromarino had netted $4.6 million in three years
of back-room dissections. He paid undertakers $1,000 a pop for
providing access to the dead, paid cutters $300 to $500 for
extracting the most marketable parts, and, according to his lawyer,
managed to take home up to $7,000 per body. (One of Mastromarino's
former employees contends the boss was pulling in double that.) The
New York Police Department later interviewed the families of 1,077
people whose bodies were raided for spines, bones, tendons, and
other tissues. BTS had cut deals with funeral homes in New York
City, Rochester, Philadelphia, and New Jersey.

The company's work was amateurish at best, dangerous
at worst. For families who planned an open-casket funeral, BTS
cutters would patch up gutted corpses as best they could.
Investigators later found legs stuffed with plastic piping of the
kind found at hardware stores. An employee said that he had used
rolls of socks to the same purpose, and police found surgical
gloves sewn up inside hastily repaired remains.

Cooke's bones were sold to Regeneration Technologies,
one of the country's largest tissue banks. The company says Cooke's
bones were deemed unsuitable for implantation, but it can't say the
same for other pieces of tissue it bought from Mastromarino. The
tissues BTS distributed ended up everywhere from a woman's neck in
Kentucky to a man's jaw in Tampa Bay. Hundreds of people wake up
every morning knowing that they are partly composed of stolen body
parts.

In February 2005, Mastromarino and three others were
indicted on 122 charges, including body stealing and opening
graves. The grisly story received perhaps more media attention than
any such scandal since a wave of body snatching in the 18th
century. A February 2006 Paula Zahn Now segment spun the
story into the perfect media narrative, complete with a villain, a
celebrity, and a whistleblower. But that telling, and many others,
failed to point out that much of Mastromarino's basic business
model was perfectly legal, common, and necessary to the biotech
industry. If Mastromarino had been smarter, he could have made a
fortune off body parts while staying well within the limits of the
law.

Consider the massive market in which Mastromarino
played but a tiny role. Demand for human tissue has never been
higher, and human remains have never been more valuable. According
to the American Association of Tissue Banks, doctors perform more
than 1 million tissue transplants each year, using everything from
secondhand ligaments to hand-me-down heart valves. That fuels a
thriving industry composed of tissue banks, biotech firms, and
middlemen. Each year the industry takes in an estimated $1 billion
in revenue, not a cent of which will go to the families or heirs of
the donors who provide the raw material.

As the Cooke scandal deepened in early 2006, the
Association of American Tissue Banks sent its members a set of
talking points, almost all of which emphasized the outlier status
of Mastromarino's operation. There are important differences
between BTS and legal banks, the association emphasized. Most
crucially, Mastromarino never sought the consent of donor families
before harvesting the tissue of their relatives. He conspired with
funeral directors, lied about the quality of the tissue, and put
transplant recipients in danger. "What these folks are alleged to
have done violates everything we stand for and everything we are
trying to do," says Robert Rigney, CEO of the association.

Yet a small but growing number of academics, doctors,
and legislators believe the Cooke scandal wasn't an aberration but
an inevitability. They believe the tissue industry as a whole, even
as it strives to distance itself from Mastromarino, is abusing
families on a scale well beyond the reach of any one body broker.
"The industry will argue that these are aberrant, isolated events
that are irrelevant," says Todd Olson, a professor of anatomy and
structural biology at the Albert Einstein School of Medicine. "My
view is it's exactly the opposite. What we're really dealing with
here is the tip of the iceberg."

Olson believes that the generosity of donors is being
abused on an "epic scale" by tissue procurement organizations,
middlemen, and biotech companies that depend on tissue for their
survival. With scientific advances there has emerged an enormously
beneficial market in remains. But the players most fundamental to
that market, donors, are locked out, prohibited by law from sharing
in the benefits that others derive from their bodies. At the heart
of this inequity is a confusion over to what extent we control our
own persons-over whether we own our increasingly valuable component
parts.

Resting in Pieces

Mastromarino found several buyers for his cadaveric
contraband, among them a highly profitable biotech firm known as
LifeCell. The New Jersey-based corporation ranked 16 on
Fortune's list of fastest growing businesses in 2006, and
with good reason: Its stock shot up 28 percent that year. The
company owes much of the success to its flagship skin graft,
AlloDerm.

"AlloDerm is a miraculous substance," says Maryland
plastic surgeon Mark Richards, "given its universal acceptance into
the human body." Doctors have found that human bodies are far less
likely to reject AlloDerm than previous skin substitutes. The graft
melts into human flesh because it is derived from human
flesh, the stripped-down product of bodies pulled apart after
death.

Surgeons use AlloDerm for all manner of
life-enhancing procedures, from reconstructive breast surgery to
hernia repair, as well as some perhaps less urgent operations.
AlloDerm injections are a leading method of lip enhancement, an
increasingly popular procedure among women. And the miracle
substance is not without cosmetic benefit for men. "Some surgeons
promote its use and employ it regularly for penis enlargement,"
says Stephen Giunta, a Virginia surgeon specializing in
phalloplasty, "even though the manufacturer advises them not to do
so."

AlloDerm is but one of many products that rely on
donated bodies for their manufacture. Another New Jersey company,
Osteotech, processes donated bone into a putty surgeons use to
patch small breaks. The publicly traded firm also sells
demineralized bone as "dental dust," a product that accelerates
healing after tooth extractions. DePuy Spine, a subsidiary of
Johnson & Johnson, crafts raw tissue into specialized
bio-implants for spinal surgery. The list of life-giving new
technologies is long and growing.

Where bodies aren't mined for raw material, they're
treasured for research. The military buys cadavers to test
explosive devices. Medical device companies buy them to test
surgical equipment. Surgeons buy them to learn to use the same.

Tissue transplants range from the critical to the
seemingly frivolous, but the industry's impact is clearly positive.
The thriving market in tissue has enhanced the lives of millions of
recipients, and it is a font of new products that will improve the
lives of millions more. Tissue transplants can give sight to the
blind and mobility to the bed-ridden. Before such operations were
routine, limbs with cancerous bones would have to be amputated; now
they can be replaced.

Law and custom both prohibit the sale of cadaveric
tissue, a ban heartily supported by bioethicists like Arthur
Caplan, the influential director of the University of
Pennsylvania's Center for Bioethics. The prohibitionists warn of
the degradation and commodification of human beings, but scientific
progress has blurred the line between tissue and commodity. Doctors
need a constant stream of remains to perform-and profit from-their
work. The current compromise treats the body as property once it's
in the hands of a corporation but as a "priceless" gift as it
passes from a donor's family into the marketplace.

"We have a schizophrenic system," explains Lori
Andrews, a professor of law at Chicago-Kent College of Law who
specializes in the legal implications of biotechnologies. Tissues,
she says, "are being treated as property by the researchers and
doctors secretly, and patients don't even realize that they have
monetary value."

Current law proscribes the compensation of donors,
ostensibly for their protection. But it also allows virtually
anyone else to buy and sell tissue. Publicly traded companies are
pumping out treatments that use the remnants of the dead to cure
the bodies of the living; the preservation of life requires the
commodification of death. "Bodies are in this stream of commerce,
and that's not ultimately a bad thing," says Michele Goodwin,
director of the Health Law Institute at DePaul University and
author of the 2006 book Black Markets: The Supply and Demand of
Body Parts. "But it's set up in such a way where only
companies, brokers, and middlepersons receive compensation, and
family members don't. It's an underhanded way of dealing with the
public."

The Invisible Hand

The legal value of a human body, dead or alive, is
zero dollars. "Under old English common law the body had no value
at all," explains Ronn Wade, head anatomist for the state of
Maryland. "Today if you look at not just transplantable tissue but
the demand for body parts for medical research and training, and
what the market will pay, the body certainly is valuable." The
actual value of the body varies widely. A Brooklyn district
attorney prosecuting the Mastromarino case says a single corpse can
fetch $250,000, though most estimates are closer to a mere
$100,000. One corpse can help heal 50 different people in the same
number of countries; a tendon might be sent to Australia, a heart
valve to India. Bones, skin, spines-all of it is worth something to
someone.

The market is thriving and global demand has soared,
but almost no one will cop to buying and selling body parts. The
1984 National Organ Transplantation Act outlaws the transfer of
"any human organ for valuable consideration" for use in
transplantation, a proscription generally taken to include tissues
as well as organs. But the law does allow for "reasonable payments
associated with the removal, transportation, implantation,
processing, preservation, quality control, and storage of a human
organ." Thus the tissue industry runs on what it deems to be
"reasonable" terms. Those who strip skin for sales are "procurers,"
not vendors; their customers are "processors," not buyers. Tissues
are not sold for prices based on demand but processed for a
"reasonable price."

The first rule of the tissue market, in other words,
is don't talk about the tissue market. Patients would be far worse
off if the trade in tissue were stanched, goes this line of
thinking. The supply of life-enhancing materials would become as
scarce as organs are now, creating shortages and jacking up prices.
But to admit that the market exists, that profits are being made,
is to risk violating the law and the social norms from which it
springs.

Some donors have found ways to play along and make a
buck, engaging the language of donation even as they exact payment.
Ova donors, for instance, can be "compensated" for their time at
virtually any price the market will bear. (See "Ova for Sale,"
October.) Blood banks pay for plasma, sperm banks for semen. By
contrast, the kin of deceased donors are never compensated, and
they probably don't even know that their relatives' tissue will be
sold.

Organs, unlike tissues, are not generally sold for
profit, and the current donation regime suffers from severe and
deadly shortages. In 1986 the Uniform Anatomical Gift Act imposed a
highly regulated system for managing organ donation. Kidneys,
hearts, and lungs are tracked, waiting lists maintained. But supply
is scarce, largely because the circumstances in which organ
donation occurs are so limited. Organ donors must be young and
healthy; typically they die of a catastrophic event such as a
motorcycle crash. The government has also designated a single
designated procurement organization for every locality. If you die
at home and donate, the government knows exactly what organization
gets to take your organs.

Tissue donation, by contrast, is lightly regulated
and totally unmapped. The government never designated organizations
for each area, and a variety of organizations compete for available
bodies. Almost anyone of any age can be a tissue donor, and tissue
never enters the tightly controlled, heavily regulated system of
organ distribution. This relative freedom has huge advantages for
burn victims and other patients who benefit from donor tissue, but
it has upset established procurement organizations that, for the
first time, have to compete for parts.

In the Washington, D.C., area, the local organ
procurement organization-the nonprofit with a monopoly on
organs-also procures tissue. Hospitals notify the Washington
Regional Transplant Consortium (WRTC) when someone is nearing
death, and the nonprofit sends out family counselors to discuss
donation with the next of kin. If consent is granted, WRTC sends a
tissue recovery team to the hospital.

Where does the recovered tissue end up? According to
Cindy Speas, WRTC's director of community affairs, the organization
is "not involved in any way with anything that is not a
not-for-profit." And it's true that the consortium doesn't send
tissue directly to corporations. Instead, WRTC provides tissue to
LifeNet, another nonprofit, whose mission is to "improve the
quality of human life" and "serve the community." LifeNet posted
$107 million in revenues in 2004 for "tissue/organ procurement,
processing fees, and reimbursements."

From LifeNet, the tissue enters the for-profit
system. LifeNet has contracted with LifeCell, the company that
makes AlloDerm, along with other "alliance partners" such as
Osteotech, the firm that makes bone putty. Standard and Poor's
lists LifeCell's value at $888 million. From there, tissue can end
up as replacement skin for a young burn victim or cosmetic filler
for a thin-lipped socialite.

LifeNet is not alone in serving as the nonprofit face
of a massive for-profit industry. The Musculoskeletal Transplant
Foundation is the world's largest tissue bank. Osteotech founded
the bank to supply it with tissue in 1987. Osteotech and the bank
are now separate entities, both pulling in a lot of cash. The
Musculoskeletal Transplant Foundation reported more than $242
million in revenue in 2004.

Six years ago, two journalists at The Orange
County Register undertook the most extensive investigation to
date of the legal tissue trade. They linked 59 nonprofit tissue
procurement agencies with publicly traded, for-profit firms. They
also called each agency for comment, and the recorded answers are a
jaw-dropping chronicle of deception and arrogance. The director of
the nonprofit California Transplant Donor Network, which at the
time was selling bone to Osteotech, admonished the
Register, "It is not legal to sell organs and tissue."
Others explained that families could not comprehend the distinction
between nonprofit and for-profit. A spokesperson for the University
of Miami Organ Procurement Agency, which sells skin and bone to the
biotech company CryoLife, explained, "We can't be educating donors
at the bedside."

Organizations like WRTC are among the most virulent
critics of shady operators like Mastromarino. They want higher
barriers to entry for brokers: a stronger Uniform Anatomical Gift
Act, a more heavily funded Food and Drug Administration with more
stringent requirements. Ideally for them, the government would
designate one tissue procurement agency per area, as it has done
with organs, and leave the big players with monopolies. "The FDA
has very stringent requirements for tissue banking," says WRTC's
Speas, "but they have not yet gotten the strictest requirements for
tissue recovery agencies. Which is why we're seeing these mavericks
out there."

Above all, such organizations emphasize the fact that
they are nonprofit, blazoning their tax status as incontrovertible
evidence of ethical purity. Within the tissue business, these
distinctions seem to hold little import. One industry expert, who
wishes to remain anonymous because he is still heavily involved in
tissue procurement, points out that employees of the nonprofit
tissue banks generally make more money than those working at
for-profit banks. Nonprofits simply turn earnings into salaries.
"‘The companies are all run very similarly," Raj Denhoy, a medical
device analyst with Piper Jaffray & Co., told the Associated
Press in November. "It isn't as if the peo­ple in these companies
aren't making a good living."

Selling the Gift of Life

Alistair Cooke never agreed to donate his body, but
most tissues in the system come from people who wanted their
remains to be reused. Hospitals, hospices, and nursing homes have
agreements with tissue procurement organizations, inviting them to
contact the next of kin as a potential donor nears death.

About 30,000 Americans donated tissue in 2005, and
the number rises every year. Anecdotal evidence suggests that most
of their families have no idea their tissue will be bought and
sold. "There is a disincentive in alerting the families as to what
might happen," says Goodwin, the DePaul University law professor,
"because the families might-I think would-oppose their family
members' ending up in the stream of commerce."

A 2001 report from the Department of Health and Human
Services found that "tissue banking and processing practices have
gradually diverged from donor families' expectations." Tissue banks
have argued that grieving families are too fragile for hard-nosed
talk about the marketplace, and no federal law requires tissue
procurement organizations to tell donors that their loved ones may
end up in a phalloplasty. The United Anatomical Gift Act includes
stringent informed consent standards for organs but is silent on
the matter of tissue.

Andrews, the biotech expert at Chicago-Kent College
of Law, says a nonprofit has asked her for legal advice on the
extent to which it must inform donor families that tissue will be
sold for profit. "The nonprofit tissue bank said, ‘We don't want to
mention [profits] because we're afraid people won't donate,' " she
recalls. "But a key provision of informed consent is that you've
got to tell people what's material to them. And if the tissue
retrieval services think this is material, that people would do
something different if they knew, then of course they have
to tell them. But oftentimes they don't."

Donor recruitment agencies are famously aggressive, a
phenomenon long observed in organ procurement. As with organ
donation, organizations can spend days coaxing a family into
consenting. This process is probably best described by the
University of Arizona sociologist Kieran Healy, who writes that we
can think of procurement professionals as having industrialized
altruism by turning it into a "resource-extraction problem." The
marketing tactics are as rich as anything Jessica Mitford cataloged
in her biting exposé of the funeral industry, The American Way
of Death, four decades ago.

Tissue banks must recruit donors and avoid scaring
away valuable, life-enhancing future parts; they need to give
donors an account of what it means to donate. Widely reported
stories like the Alistair Cooke debacle threaten to lower the pool
of donors, so agencies have responded with media outreach. Like
never before, organizations need to reassert control over the
cultural narrative of donation. In large part, that has meant
taking control of the language, turning the lexicon of scandal into
the preferred patois of altruism. "I'd adore it if you'd look at
the language we like to use," pleads Speas of the WRTC. "We don't
like to use the word harvest."

The language WRTC would like journalists to
use is compiled in a "reporter's guide" available on the
organization's website, a compact manual of right and wrong words
for journalists. The offending harvest has a line through
it; the consortium suggests recovery. Retrieval is
similarly verboten, as are cadaveric and brain
death. The preferred terms are described as "the correct media
terminology," as if they've been deemed acceptable by some
centralized bureau of semantic and reportorial accuracy.

This is framing, and donor procurement agencies are
well-versed in the art. "How much will it cost my family to donate
my tissue and organs?" reads a question from a FAQ on the website
of Community Tissue Services, an Ohio-based nonprofit. "There is no
cost," reads the reply, as if the organization were offering a
valuable service at bargain rates.

At times, the language of donation and the language
of medicine are just a mouse click away. Take LifeNet, the Virginia
nonprofit-not to be confused with LifeBanc of Ohio, LifeGift of
Texas, LifeSource of Minnesota, or LifeLink of Florida. LifeNet
runs two sites in two disparate languages, one donor-friendly and
one doctor-friendly. Accesslifenet.org is for customers looking to
buy, not families looking to give. The site stresses quality
control, the engineering process, and service. "LifeNet's
processing facilities," it explains, "are state of the art and have
been designed to minimize the risk of cross-contamination. They
meet stringent regulatory, industry, and ISO standards. LifeNet's
allograft tissues undergo extensive development to ensure that the
products meet the surgeon's needs and preferences." Images of
white-coated doctors confer an air of clinical legitimacy, just
above a note that customer service representatives are available
"24 hours a day, 365 days a year."

LifeNet's "Donor Family Services Department" runs a
very different site, healingthespirit.org, with a stated mission to
"promote healing and peace for organ and tissue donor families."
The site's main image shows dappled light pouring through a canopy
of trees, the font of choice is a feminized cursive, and the sound
of running water loops endlessly in the background.

The Barnard anthropologist Lesley Sharp has called
such framing "the greening of the body." "Throughout the 1990s,"
she writes in the March 2001 issue of American
Anthropologist, "organ transfer has experienced an astounding
proliferation of metaphorical language and ecological imagery." The
imagery advances the idea that loved ones are being recycled,
reborn through the gift of tissue. Donor agencies spurn thoughts of
decay, death, and the loss of a specific person, steering patients
toward highly generalized ideals of life and regeneration. The
industry's websites and literature include far more portraits of
beaming toddlers than of the elderly who provide most of the
tissue.

Where donor agencies do address loss, the language is
elusive, metaphorical, and almost comically devoid of content. A
FAQ explains that "all grief is unique," and family members can
send any questions about their own grief to a "bereavement
specialist" by email. Customer service reps may be available 24/7,
but the bereavement specialist requires at least one week to think
up an answer. "You are brave to weather the pain of grief," reads
one such long-awaited response. "It is a long road and a demanding
journey, and not one that others can navigate for us."

Donor families are invited to add to an "online
memory quilt," an oddly digital expression of grief suspended in
cyberspace. Grieving family members are asked to choose from a list
of greeting card-like messages, such as "Love so simple, so pure,
so true...all in one precious bundle...perfect beyond belief." They
then choose from a set of brightly colored pictures-balloons, teddy
bears, hearts-and add the square to the pixelated quilt.

The Disassembly Line

Predictably, the industry claims all of this is for
the benefit of the donor family. Donor interests and those of the
procurement organization are assumed to be identical. Speas says
careful word use is necessary to protect grieving donor families
from even more sorrow as they send a relative's body into the
donation process. "With the BTS scandal, all the old words were
used," she complains, "which makes the donor families who have
given the gift just cringe. You know, it's really all about
them."

P.R. machines like LifeNet and WRTC have
well-established systems for recruiting and processing donors. WRTC
has been around for 20 years, and for most of that period its
monopoly on local organ donation prevented it from having to
compete for the dead. But since no such monopolies are mandated for
tissue donation, entrepreneurs have appeared, encouraged by
insatiable demand.

One of those businessmen is Brent Bardsley, co-owner
of the Anatomy Gifts Registry (AGR) in Hanover, Maryland. Brent and
his brother Jim started out as tissue recovery coordinators at the
Institute for the Advancement of Medicine, a nonprofit that
recovers fetal tissue from terminated pregnancies for research
purposes. In 1995 they decided to strike out on their own, founding
AGR and eventually focusing on the recovery of adult cadaveric
tissue, all of it gifted by altruistic donors.

AGR is officially a nonprofit, but it is also very
much a start-up venture, and its operations reveal a lot about the
tension between the rhetoric of altruism and the reality of the
marketplace. Its headquarters sits in the last of a long row of
single-story brick buildings near the Baltimore airport. Little
distinguishes the outfit from its neighbors, most of which have
chosen this location for the same reason: proximity to delivery
planes. Some of the neighboring businesses are sending electronics
all over the country and the world. Bardsley is doing the same with
body parts.

Jim and Brent Bardsley process 40 to 50 donated
bodies a month, extracting pieces and sending them off to medical
device companies. Procuring tissue for research is less lucrative
than selling parts for transplantation, but it is also subject to
fewer regulations. When regulators complain that "you can start a
tissue bank in a garage," they're talking about places like
AGR.

Indeed, AGR is part garage, part laboratory. As Jim
and Brent show me the cavernous main storage site, a white van
backs right into the facility. A woman jumps out, opens the back of
the van, pulls out a covered body, and feeds it into a body cooler.
One side of the cooler opens at the drop-off point, and the other
end opens into a dissection room. "We invented that system," says
Brent, hands on his hips, ever the can-do business owner. Cracking
open the body cooler to offer me a peek, Jim warns, "It's pungent
in here."

The dissection room is small, cold, and filled with
steel. A couple of sinks line one wall; dissection tables line the
other. At harvest time, two of the Bardsleys' six technicians will
dissect a body at once. The two will look to fill specific orders:
limbs, internal organs, brain tissue, joints, and whatever else
researchers have requested. "We try to customize the recovery to
maximize the donation," Brent explains, "to use as many tissues as
possible."

A steel specimen refrigerator holds extracted parts
until the serological results come back, when they will be released
for sale. Until then, the parts are wrapped in blue plastic and
stored in freezers. The plastic package I'm staring at, Jim informs
me, contains a pelvic girdle.

The Bardsleys are clearly more excited about an
adjacent lab they're still preparing for use. As their business
expands, they want a room to rent out so clinicians can train there
in the facility, and they're building a sterile white space to meet
the latest biosafety standards. At the same time, much in the
facility is secondhand equipment cast off by medical schools.
"That's a vintage autopsy sink," Jim says, pointing.

Back in the cavernous main facility, 20-odd freezers
contain parts waiting to be shipped to medical device companies:
spines, joints, whole torsos. On a raft above us are a set of
Styrofoam containers for packing. The room is dominated by a tall,
jet-black machine in its center. Brent flips it open to reveal a
tiny pile of ashes and bone fragments. All the parts that don't
make it to the airport come here, to the cremator. When the ashes
are ready, they're scooped into a plastic black box for mailing,
labeled with the tracking number.

AGR does not price parts based on demand. After all,
on paper the Bardsleys aren't selling parts at all. They're selling
recovery services at a "reasonable price." Because the same amount
of effort goes into recovering a cadaver heart as a cadaver lung,
internal organs cost one flat fee: The cost of a heart is the cost
of a lung.

Brent says he hasn't made up his mind about whether
donors should be paid for parts, but he understands the contention
that donors deserve a piece of the pie. "Organizations are standing
to make money, and why shouldn't the public be able to
participate?" he reasons. But when money is involved, he adds, "the
federal government views this as coercing people to donate. We
can't be perceived as coercing people."

The Bardsleys have been criticized as unscrupulous
simply for covering cremation costs for donors; they are assumed to
"coerce" poor families into donating by absorbing the cost of
disposal. The resistance to allowing cash for payment, says Brent
Bardsley, would be far stronger.

But the Bardsleys do more than most to accommodate
families; they're new and agile, making up the rules as they go
along. Donor families worry about whether the ashes they get belong
to their loved ones, so the Bardsleys have installed security
cameras to record the drop-off-to-cremation cycle. Families
sometimes want remains directed to certain research areas; when
this is possible, AGR tries to comply. What families don't want, in
many cases, is to know exactly what's going on-though the Bardsleys
will show the facility upon request. "Most people," Brent comments,
"don't ask for the grand tour."

Scandal and Reform

During the last five years, scandals involving tissue
procured and resold illegally have chipped away at the neat
separation between altruistic donation and big business. UCLA,
Tulane, the University of Texas Medical Branch, and the University
of California at Irvine have all been accused of reselling bodies
donated for research. To get a sense of how many lawsuits are
currently pending, consider the way corporations have come to
calibrate their legal troubles. "Of all the cases filed in state
and federal court," LifeCell attorney David Field recently boasted
to the Associated Press, "it appears less than five possibly
involve LifeCell."

Doctors, journalists, and legislators are apt to
blame the profusion of scandal on the pursuit of profit. Calls for
reform rarely suggest that donors should be compensated; profit is
perceived as the problem, not the solution. In April Sens. Charles
Schumer (D-N.Y.) and Patrick Leahy (D-Vt.). introduced the Safe
Tissue Act, a bill that would, among more defensible measures,
require the secretary of health and human services to "promulgate
regulations defining ‘reasonable payments' " for procuring and
processing tissue. Instead of letting middlemen set their own
prices, the government would set the cost of recovering tissue and
thus the price of parts.

The bill never made it out of committee, though it is
indicative of the quality of solutions currently on the table.
Price controls would do nothing to remove profit from the system of
exchange; biotech firms would still buy, manipulate, and resell the
tissue. While firms may find themselves paying less for donor
tissue under such a regime, families would remain uncompensated and
uninformed. The market would remain intact and unacknowledged,
exploiting donors and their families.

The alternative reform-compensating donors, the
crucial source of material upon which life-giving treatments
depend-has hardly been discussed. Tissue markets are a well-kept
secret, and when scholars talk about creating markets for body
parts, they're usually talking about kidneys, not skin and bone.
The key difference between tissue markets and organ markets is that
the former don't have to be created; they are already the primary
means by which tissue finds its way from donor to recipient.

Compensation to donors might take a variety of forms,
from reimbursement of funeral expenses to charitable donation to
direct payment. Tissue is already treated as property once it is
processed; if it were legal property before it left the donor's
body, sales would go to donors' estates along with other assets.
Profits from their sale would be willed along with the house and
the car, left to favored grandchildren and pet causes.

Many bioethicists worry that payment will create a
two-tiered system, in which the bodies of the poor are repurposed
to serve the rich. This argument assumes that those looking to sell
tissue would be done material harm by actually selling it-that the
mere choice to sell is a form of coercion. Goodwin, the DePaul
professor and Black Markets author, argues that the poor
have the most to gain. "I don't see any logic in allowing companies
to harvest individuals' body parts purely for financial gain," she
says, "and meanwhile denying individuals the opportunity to pay off
the costs of funeral homes and medical expenses when their
relatives die. Think about the cost that poor families experience
currently when they have to bury relatives. Their options are,
well, do we sell some furniture to pay for this funeral? Do we sell
the car?"

The potential for wealth transfer is significant and,
given the pace of biomedical advance, sure to increase. And a
formal market has another benefit, one whose necessity becomes more
evident with each successive scandal: transparency. The same lack
of transparency that discourages nonprofits from talk of
moneymaking allowed Michael Mastromarino to strip-mine thousands of
bodies, confident that potential donors wouldn't ask questions and
biotech firms wouldn't look beyond the falsified records.

Exploitation and Repugnance

The history of transplantation has been one of
overcoming visceral opposition-of rejecting what the prominent
bioethicist Leon Kass calls "the wisdom of repugnance." Kass, the
former head of the President's Council on Bioethics, believes
disgust to be "the emotional expression of deep wisdom." Wise or
otherwise, repugnance has always fueled opposition to
transplantation. When doctors performed the first successful kidney
transplant in 1954, they were accused of playing God and
cannibalizing the dead. When a South African doctor performed the
first heart transplant 13 years later, he was met with the same
refrain. Critics feared this new conceptual distance from the body;
they warned of a future in which men and women treat the human
machine like a run-down car, trading in old parts for new.

Half a century later, such predictions look less
hysterical than prescient, less nightmarish than benign. Other
medical advances have accelerated the process by contributing to
general longevity, increasing the likelihood that an individual
will wear out old parts-shot knees, worn joints-and find himself
needing a replacement. It wouldn't have comforted the critics to
know it, but the ability to exchange human parts has become
routine, its absence unthinkable. The slope has indeed been
slippery, and the benefits have been incalculable.

What remains of that initial repugnance is arbitrary
and inconsistent. Patients have no problem paying for replacement
parts, paying the surgeons who will implant them, paying the vast
array of medical professionals who will nurse them back to health.
For all the crowing over the benefits of altruism, no one has
suggested that surgeons are tainted by the market that pays them so
well; no one seems upset that biotech companies sell rather than
donate their treatments. Patients and doctors cheer as new
technologies find their way into the stream of commerce but recoil
in revulsion at the thought of paying the donors at the source.

Beyond the visceral revulsion at Michael
Mastromarino's ghoulish raids lies a bigger and more important
story, one that offends on another level. The tissue trade in its
current form violates basic ideas of fair play, free exchange,
equity, and honesty. These are wrongs at which our sense of
repugnance has not diminished.

The Mastromarino scandal continues to unfold. In
October 2006, Brooklyn prosecutors issued yet another indictment,
accusing Mastromarino of enterprise corruption. Two Philadelphia
funeral homes were forced to close, and seven New York funeral
directors pled guilty to related charges. A raft of post-transplant
patients filed lawsuits, with others as far as Britain threatening
to pile on.

Mastromarino, out on $1.5 million in bail, is looking
at a possible 25 years in prison. Meanwhile, LifeCell is set to
report its most profitable year ever.